Retrospective analysis of radiological investigation of surgically excised head and neck lipomas.

PURPOSE: Differentiating benign lipomas from malignant causes is challenging and preoperative investigative guidelines are not well-defined. The purpose of this study was to retrospectively identify cases of head and neck lipomas that were surgically resected over a 5-year period and to identify the radiological modality chosen and features discussed in the final report. Multidisciplinary outcomes and pathology reports were examined with a view to identifying high risk features of a lipoma to aid in future risk stratification. METHODS: Retrospective chart review of pathology characteristics, radiological features (modality, size, calcifications, septations, globular/nodular foci), multidisciplinary discussion and history of presenting complaint was performed. RESULTS: Two liposarcomas and 138 lipomas were identified. Twenty-two percent of all lipomas received radiological investigation. Twenty-two percent of imaging referrals were possibly inappropriate. Furthermore, radiological features suggestive of malignancy were not present in the final radiology report, X2 = 28.8, p < 0.0001. CONCLUSION: As expected, the incidence of liposarcoma is low. There is limited awareness of radiology referral guidelines superimposed with a tendency to over-investigate lipomas. Furthermore, radiological features suggestive of malignancy were inconsistently reported on and not documented in multidisciplinary discussions. Therefore, we propose a multidisciplinary checklist for referring physicians and radiologists to aid in diagnostic work-up.

Frequency of inter-specialty consensus decisions and adherence to advice following discussion at a weekly neurovascular multidisciplinary meeting.

BACKGROUND/AIMS: Data are limited on the frequency of 'consensus decisions' between sub-specialists attending a neurovascular multidisciplinary meeting (MDM) regarding management of patients with extracranial carotid/vertebral stenoses and post-MDM 'adherence' to such advice. METHODS: This prospective audit/quality improvement project collated prospectively-recorded data from a weekly Neurovascular/Stroke Centre MDM documenting the proportion of extracranial carotid/vertebral stenosis patients in whom 'consensus management decisions' were reached by neurologists, vascular surgeons, stroke physicians-geriatricians and neuroradiologists. Adherence to MDM advice was analysed in asymptomatic carotid stenosis (ACS), symptomatic carotid stenosis (SCS), 'indeterminate symptomatic status stenosis' (ISS) and vertebral artery stenosis (VAS) patients, including intervals between index event to MDM + / - intervention. RESULTS: One hundred fifteen patients were discussed: 108 with carotid stenosis and 7 with VAS. Consensus regarding management was noted in 96.5% (111/115): 100% with ACS and VAS, 96.2% with SCS and 92.9% with ISS. Adherence to MDM management advice was 96.4% (107/111): 100% in ACS, ISS and VAS patients; 92% (46/50) in SCS patients. The median interval from index symptoms to revascularisation in 50-99% SCS patients was 12.5 days (IQR: 9-18.3 days; N = 26), with a median interval from MDM to revascularisation of 5.5 days (IQR: 1-7 days). Thirty patients underwent revascularisation. Two out of twenty-nine patients (6.9%) with either SCS or ISS had a peri-procedural ipsilateral ischaemic stroke, with no further strokes/deaths during 3-months follow-up. CONCLUSIONS: The high frequency of inter-specialty consensus regarding management and adherence to proposed treatment supports a collaborative/multidisciplinary model of care in patients with extracranial arterial stenoses. Service development should aim to shorten times between MDM discussion-intervention and optimise prevention of stroke/death.

The Impact of Preinjury Antiplatelet and Anticoagulant Use on Elderly Patients with Moderate or Severe Traumatic Brain Injury Following Traumatic Acute Subdural Hematoma.

BACKGROUND: Although it is often assumed that preinjury anticoagulant (AC) or antiplatelet (AP) use is associated with poorer outcomes among those with acute subdural hematoma (aSDH), previous studies have had varied results. This study examines the impact of preinjury AC and AP therapy on aSDH thickness, 30-day mortality, and extended Glasgow Outcome Scale at 6 months in elderly patients (aged ≥65). METHODS: A level 1 trauma center registry was interrogated to identify consecutive elderly patients who presented with moderate or severe traumatic brain injury (TBI) and associated traumatic aSDH between the first of January 2013 and the first of January 2018. Relevant demographic, clinical, and radiological data were retrieved from institutional medical records. The 3 primary outcome measures were aSDH thickness on initial computed tomography scan, 30-day mortality, and unfavorable outcome at 6 months (extended Glasgow Outcome Scale). RESULTS: One hundred thirty-two elderly patients were admitted with moderate or severe TBI and traumatic aSDH. The mean (±SD) age was 78.39 (±7.87) years, and a majority of patients (59.8%, n = 79) were male. There was a statistically significant difference in mean aSDH thickness, but there were no significant differences in 30-day mortality (P = 0.732) and unfavorable outcome between the AP, AC, combined AP and AC, and no antithrombotic exposure groups (P = 0.342). CONCLUSIONS: Further studies with larger sample sizes are necessary to confirm these observations, but our findings do not support the preconceived notion in clinical practice that antithrombotic use is associated with poor outcomes in elderly patients with moderate or severe TBI.

C-arm cone-beam CT parenchymal blood volume imaging for transarterial chemoembolization of hepatocellular carcinoma: implications for treatment planning and response.

We report on the feasibility of C-arm cone-beam computed tomography (CBCT) parenchymal blood volume imaging (PBVI) performed immediately following transarterial chemoembolization (TACE) of hepatocellular carcinoma (HCC) to assess the need for repeat treatment. Eighteen TACE procedures were included. A retrospective assessment was made for the presence or absence of residual disease requiring treatment on immediate post-TACE PBVI and on interval follow-up multidetector computed tomography (MDCT) or magnetic resonance imaging (MRI). In 9/18 cases, both PBVI and MDCT/MRI showed that no further treatment was required. In 6/18 cases, further treatment was required on both PBVI and MDCT/MRI. In three cases, PBVI showed that further treatment was not required but MDCT/MRI showed residual disease requiring repeat treatment. There were no cases with PBVI showing residual disease not detected on follow-up MDCT/MRI. The PBVI sensitivity for detecting disease requiring repeat TACE was 67% (95% confidence interval [CI] 30-93%), and specificity was 100% (95% CI 66-100%). The use of C-arm CBCT PBVI for the detection of residual viable tumor within a treated lesion immediately after TACE is feasible. It may allow repeat TACE to be planned without performing interval imaging with MDCT or MRI.

Prostate MRI using an external phased array wearable pelvic coil at 3T: comparison with an endorectal coil.

PURPOSE: To evaluate T2w and DWI image quality using a wearable pelvic coil (WPC) compared with an endorectal coil (ERC). METHODS: Twenty men consecutively presenting to our prostate cancer MRI clinic were prospectively consented to be scanned using a wearable pelvic coil then an endorectal coil and pelvic phased array coil at 3T. Eighteen patients were suitable for inclusion. Axial T2w images were obtained using the WPC and ERC, and DWI images were obtained using the WPC, ERC, and PPA. Analysis was performed in consensus by two readers with experience in prostate MRI. The readers scored the T2w images using six qualitative criteria and the DWI images using five criteria. Signal-to-noise ratio (SNR) was also measured. RESULTS: T2w artifact severity was greater for an ERC than a WPC (p = 0.003). There was no significant difference in T2w qualititatve image quality by other measures. The distinction of zonal anatomy on DWI was superior for an ERC compared with both a WPC and a PPA (p = 0.018 and p < 0.001 respectively), and there was no significant difference in DWI image quality by other measures. SNR was significantly higher for ERC imaging for both T2w and DWI. CONCLUSION: WPC imaging provides comparable image quality to that of an ERC, potentially reducing the need for an ERC. WPC imaging shows reduced T2w artifact severity and inferior DWI zonal anatomy distinction compared with an ERC. Imaging with a WPC produces a lower SNR than an ERC.

Acute-onset abdominal pain in a woman in her 30s.

CLINICAL INTRODUCTION: A woman in her 30s presented to the emergency department with sudden-onset abdominal pain with hypotension and tachycardia. She gave a history of congenital heart disease for which she had previously undergone multiple operations. On examination she demonstrated right upper quadrant tenderness. She underwent an urgent multiphase CT (figure 1A-C).heartjnl;105/4/275/F1F1F1Figure 1(A) Arterial phase coronal CT. (B) Arterial phase axial CT. (C) Portal venous phase axial CT. QUESTION: What is the underlying liver pathology?Hepatocellular adenomaCholangiocarcinomaHepatocellular carcinomaFocal nodular hyperplasiaHepatoblastoma.

Diagnostic Utility of Computed Tomographic Angiography in Giant-Cell Arteritis.

Background and Purpose- The diagnosis of giant-cell arteritis (GCA) is challenging. Superficial temporal artery biopsy and ultrasound are positive in only 50%. We evaluated computed tomographic angiography (CTA) of the head in GCA. Methods- This case-control study was performed using a prospective GCA registry. Cases presented with stroke symptoms, had a CTA, and were subsequently diagnosed with GCA. Age- and sex-matched controls presented with stroke symptoms, had a CTA, and were not diagnosed with GCA. CTAs were evaluated for the presence of superficial temporal artery abnormalities. Results- Fourteen cases met the inclusion criteria and were matched with 14 controls. Blurred vessel wall margins and perivascular enhancement was found in 10 cases (71.4%) and 2 controls (14.3%). CTA has an accuracy of 78.6%, sensitivity of 71.4%, and a specificity of 85.7% for GCA. Conclusions- CTA detects superficial temporal artery abnormalities in GCA. This may facilitate early diagnosis and prompt implementation of potentially sight-saving and stroke-preventing treatment.

Diagnostic accuracy of standard axial 64-slice chest CT compared to cardiac MRI for the detection of cardiomyopathies.

OBJECTIVE: To assess the diagnostic accuracy of standard axial chest CT compared with cardiac MRI for cardiomyopathies. METHODS: The standard axial 64-slice chest CTs of 49 patients with cardiomyopathies and 27 controls were blindly assessed for the presence of a cardiomyopathy by two independent readers. Qualitative and quantitative analysis included assessment of: (i) interatrial septal thickness, (ii) left atrial diameter, (iii) myocardial hypertrophy, thinning or fat, (iv) myocardial and papillary muscle calcification, (v) papillary muscle thickness, (vi) calcified coronary artery segments, (vii) left ventricular (LV) diameter, (viii) interventricular septal thickness and (ix) right ventricular diameters. Cardiac MRI was the gold standard. RESULTS: There were 21 (42.9%) dilated, 16 (32.7%) hypertrophic, 8 (16.3%) ischaemic and 4 other (8.2%) (LV non-compaction × 2, amyloid, idiopathic restrictive) patients with cardiomyopathies. An LV diameter of 47 mm, interventricular septal thickness of 14 mm and coronary artery/papillary muscle calcification on axial chest CT best distinguished dilated, hypertrophic and ischaemic cardiomyopathies from controls, respectively; kappa = 0.45 (moderate interobserver agreement). The sensitivity (95% confidence interval), specificity, positive- and negative-predictive values (95% confidence interval) and diagnostic accuracy of chest CT in diagnosing cardiomyopathies were 68% (52-83), 100%, 100%, 66% (55-85) and 80%, respectively. CONCLUSION: Cardiomyopathies may be detected on standard chest CT with good sensitivity and high specificity. ADVANCES IN KNOWLEDGE: It is useful to assess for an underlying cardiomyopathy on standard chest CT, especially in a patient with unexplained dyspnoea.